Injury description (body part injured, i.e., first joint of left index finger)

Is diagnosis causally related to this industrial accident?

Employer information (Where is this injured worker employed?)

Employer name

Employer address

Employer telephone

Provider information

Initial treating provider name and BWC provider number (may be a hospital or physician)

Name of physician of record and BWC provider number (If the provider sends his or her BWC provider number to the MCO, BWC will send the provider, who reported the injury or the provider of record, a letter with the status of the claim and the allowed conditions.)